Assessment and resuscitation of the shocked child is a complex and difficult topic even for those whose daily job it is to manage such situations. All the weirder, then, the college decision to include this specialised paediatric topic in their general adult intensive care examination process. It is unclear how detailed knowledge of this area identifies an adult intensivist as somebody deserving specialist-level accreditation. Certainly it enhances your practice, insofar as any medical knowledge does - but it is hard to argue that it forms a part of some sort of core body of essential knowledge.
The topic of burns appears in the Part II CICM exam in a number of ways. Typically, as a part of the question, the candidate is either expected to list the characteristic findings of airway burns and smoke inhalation injuries, or to discuss fluid resuscitation for the burns patient. Whenever this is not the case, a generic "discuss your management" question is to be expected. Occasionally the patient is paediatric, but the "paediatricity" of the patient does not exert overmuch influence on the discussion of the burns management.
A plan of management for a difficult intubation is (fairly) expected of senior ICU trainees, and has come up several times over the last few years. It can be expected to remain a routine part of the exam process. As such, the savvy candidate will memorise a certain management algorithm, and will be ready to regurgitate it at the appropriate moment.
Question 9 from the first paper of 2014 is the only past paper SAQ to ask about paracetamol toxicity directly. This topic's representation in the exam in disproportionate to its prevalence in practice. It certainly comes up more often if one works in a "liver unit", but its appearance in ICUs elsewhere is sufficiently common that it should warrant more of a discussion.
Pneumonectomy and its complications have not enjoyed very much attention in the CICM fellowship exam. Historic instances of their appearrance in the exam papers are limited to Question 19 from the second paper of 2018 and Question 4 from the second paper of 2009, of which the latter presents us with a situation where a post-pneumonectomy patient has come back from the operating theatre with the chest drain attached to an underwater seal tube. More on that later.
Historically, the college examiners have been interested mainly in the influence of age on the outcome of ICU stay. For instance, a detailed all-systems look at age-related changes in the response to critical illness can be found in Question 8 from the second paper of 2007:"What are the age related factors which adversely affect outcome in the elderly (>65 years) critically ill patient?" . Other similar questions include Question 9 from the first paper of 2012 (outcome from traumatic brain injury in the elderly), Question 30 from the first paper of 2009 (tools of functional assessment) and the identical Question 17 from the first paper of 2006.
Question 13 from the second paper of 2002 asked to compare PCA and thoracic epidural in the setting of rib fractures. Pain management in chest injuries is also touched upon in the answer to Question 26 from the first paper of 2010, "Outline the relative advantages and disadvantages of thoracic epidural analgesia compared to systemic opioid analgesia via a PCA (Patient Controlled Analgesia)"
This collection of trauma trials and guidelines should serve as a sort of suggested reading material for the CICM Second Part exam candidate preparing for the increasingly unpredictable Fellowship exam, to supplement the increasingly inadequate practice of revising by doing past papers.
N.meningitides featured in Question 10 from the second paper of 2002: "Outline the diagnostic features, complications and treatment of patients with meningococcal sepsis." It also appeared in the ABG interpretation scenario for Question 3.1 from the second paper of 2015, where the trainees were expected to identify the meningococcaemia on the basis of "fever, headache and a widespread rash". The patient also had a horrific blood gas with features of hypoadrenalism, consistent with Waterhouse-Friedrichsen syndrome.A good NEJM review article is available which covers this territory well. It is the source for most of the information offered in the summary below. If one wished to cultivate an intimate acquaintance with N.meningitides, one may consider reading Rouphael and Stephens' massive opus from 2012.
Question 9 from the second paper of 2012 asked vaguely about "clinical and organisational issues involved pre-transfer" in the context of trying to ship a subarachnoid haemorrhage survivor out of a backwater dungheap and into a neurosurgical unit. The answer to all such questions can be found in college policy documents. ANZCA also have a policy document- Guidelines for Transport of Critically Ill Patients- which has been endorsed by CICM. Additionally, CICM have a policy document - Minimum Standards for Transport of Critically Ill Patients (IC-10, 2010) which is referred to in the college answer. This document provides a reasonable systematic framework for a good quality answer.
This is a summary of sepsis and infectious diseases trials and guidelines, aimed at the CICM Part 2 exam candidate. The objective was to list the important studies, link to an authoritative analysis, and produce a pithy one-liner to help remember the main points.
Peripartum sepsis is most often of genitourinary origin. The organism carrying the highest mortality is S.pyogenes and the most common organism is E.coli.. Source control (eg. evacuation of retained products) is key to the managament.
At a basic level, the SMR is a measure of how good your unit is at preventing acute illnesses from killing patients. This seems like an important metric, and indeed much is made of the SMR in the critical care community, at least locally. Units with well-developed media machinery use favourable SMR data to advertise their supremacy as centres of excellence; units which perform poorly use damning SMR data as a kick in the arse required to stimulate policy change.The college loves SMR. Specifically, they like to discuss which it might be abnormally high, and what are its limitations as a measure of the quality of care.
The osmolar gap is a diagnostic tool which can help identify the presence of some foreign solute in the body fluids. In the CICM fellowship SAQs, it for some reason mostly identifies young women who have ingested a toxic alcohol.